Apply on line at http://www.alohacare.org/Careers/Default.aspx
The Company:
AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all. This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment. As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii.
The Culture:
AlohaCare employees share a passion for helping Hawaii’s most underserved communities. This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication, and a generous benefits package.
AlohaCare’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare has a strong commitment to support Hawaii’s families and reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect, and trust with both our internal and external customers, we encourage open-door, two-way communication through daily interactions, employee events and quarterly all-staff meetings. AlohaCare’s comprehensive benefits package includes low-cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.
These employee-focused efforts contribute to a friendly, team-oriented culture which is positively reflected into the communities we serve.
The Opportunity:
The Geriatric Resources for Assessment and Care of Elders (GRACE) Social Worker is responsible for coordinating geriatric care with the GRACE Registered Nurse for AlohaCare adults 50 years of age or older with geriatric conditions receiving health care in an affiliated health care system. GRACE Team Care offers home-based geriatric assessment and care management as part of an interdisciplinary team for individuals who have geriatric conditions. In collaboration with the GRACE Registered Nurse, the primary care physician and the GRACE interdisciplinary team, the GRACE Social Worker evaluates an adult’s behavioral and social determinants of health as well as the medical and functional status with the GRACE Registered Nurse and works to implement a comprehensive treatment plan of coordinated care that supports the individual’s goals, strengths and preferences and maximizes the health potential and quality of life of the member. The GRACE team’s working relationship and communication with the Primary Care Team is key to the success of the GRACE program The GRACE social Worker is expected to coordinate care with the PCP and GRACE support team for vulnerable older adults who are at risk for geriatric complications and functional decline. By engaging and educating families and caregivers involved in the adult’s care, the GRACE registered nurse works to promote the individual’s maximum functioning and quality of life.
The catalyst of the GRACE model is the GRACE support team which consists of the social worker and registered nurse. In collaboration with the PCP, the support team works closely together to assess the individual, develop, and implement a care plan, evaluate, and treat geriatric conditions, and provide longitudinal care management and coordination of care.
Job Summary:
The GRACE Social Worker is responsible for conducting face-to-face assessments, developing individualized health action plans, interacting with members, providers, and physicians to coordinate primary, acute, behavioral, and long-term services and supports (LTSS) for individuals having special health care needs enrolled in the GRACE program. Job functions are performed in accordance with requirements of the QUEST Integration contract, GRACE training manual, and health plan goals and quality outcome metrics.
Primary Duties and Responsibilities:
- Conducts face-to-face or virtual (video chat) Health and Functional Assessments (HFA) for all Special Health Care Needs, Expanded Health Care Needs, Community Integration Service Needs, or Community Care Service and GRACE needs members enrolled in GRACE on an annual or more frequent basis (as applicable) and a Level of Care Assessment (DHS Form 1147) for members needing long term care.
- Engages GRACE member/providers to participate in the assessment process and collaboratively develop a person-centered Health Action Plan for each member, based upon the HFA, DHS-1147, or other assessments.
- Interacts with member, family, physician(s), and other providers utilizing clinical and social knowledge and expertise to determine the member’s current status and capacity and to assess the options for service delivery including use of health plan benefits and community resources to update a Member’s Health Action Plan.
- Solicits input into the ICP from a multi-disciplinary team of GRACE registered nurse, geriatrician, pharmacist, and mental health liaison.
- Activates the GRACE protocols and team suggestions for care related to geriatric conditions.
- Meets with the member at a minimum every 90 days in person or via video chat to monitor and document the Member’s progress in the Health Action Plan.
- Alternates with GRACE Registered Nurse to perform monthly outreach either by phone or in person to proactively monitor and assist member in pursing member’s goals.
- Provides supportive counseling with the Member and caregiver in understanding the illness and coping with the impact of the illness, as well as addressing end-of-life and bereavement issues as applicable.
- Screens for social risk factors and incorporate information on the results of positive screens into clinical decision making and offer screened members interventions to mitigate the impact of social risk factors, including timely referrals with positive screens.
- Assists the member with connecting to social services to help find and apply for housing necessary to support the individual in meeting their medical care needs.
- Enters all contact with the Member and his/her family or caregivers in the electronic record to ensure information on the GRACE Member is shared with the GRACE team.
- Ensures the Health Action Plan is a person-centered individualized plan that is developed with the Member and/or authorized representative and with input from other GRACE team members, is based on an assessment and developed within no more than 30 calendar days of completion of the assessment.
- Facilitates authorization and access to services.
- Verifies authorized or coordinated services have been provided.
- Monitors and resolves any concerns about service delivery or providers and ensures that the services being provided are meeting the member’s needs.
- Surveys members to ensure GRACE member satisfaction with providers and services.
- Provides individualized education on preventative health care measures.
- Provides information on HCBS alternatives to nursing facility placement and the choice of Self-Direction of HCBS.
- Monitors and performs health coordination activities for members in Self-Direction program.
- Monitors the Electronic Visit Verification portal for completed visits including completion of time sheets when needed.
- Evaluates the need for specialized behavioral health care and, if necessary, initiates a referral.
- Refers to and works with Hawaii CARES to ensure Members receive, SUD, mental health, and co-occurring treatment and recovery support services, as well as crisis intervention and support services in a timely manner.
- Coordinates care with GRACE members receiving services through AMHD, CAMHD and DDD programs.
- Provides ongoing GRACE coordination and continuity of care for GRACE members.
- Assists GRACE members in transitioning between hospital, nursing facility, other congregate settings and other community-based locations ensuring a seamless and continuous coordination of care across a continuum of care.
- Attends additional provider meetings as needed to review, modify, and prioritize the individualized care plan (HAP).
- Attends and assists with facilitation of weekly GRACE interdisciplinary team meetings to review the implementation of the ICP.
- Performs team reviews at one, two, three, six and nine months following the initial team care planning conference and additional team reviews if the member is hospitalized or has an emergency department visit.
- Refers to and works with Hawaii CARES to ensure Members receive, SUD, mental health, and co-occurring treatment and recovery support services, as well as crisis intervention and support services in a timely manner.
- Coordinates care with GRACE members receiving services through AMHD, CAMHD and DDD programs.
- Maintains accurate written documentation and records of health coordination and GRACE activities in computer system according to appropriate service coordination and/or clinical guidelines.
- Ensures compliance with all state and federal regulations, including HIPAA standards of confidentiality of protected health information, reporting of critical incidents and reporting of quality-of-care issues.
- Performs other duties as assigned.
- Responsible to maintain AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.
Required Competencies and Qualifications:
- Experience with serving members with geriatric conditions in the community.
- Health plan experience with care coordination responsibilities.
- Experience with Medicare / Medicaid programs.
- Experience with individuals who have special health care needs, including HIV/AIDS, developmental disabilities, medically fragile, older adults, and individuals with physical disabilities.
- Prior nursing home diversion or long-term care case management experience serving members in the community.
- Previous experience in discharge planning.
- Intermediate computer skills and experience with Microsoft Office products.
- Must be organized and detail oriented.
- Must possess strong written and verbal communication and presentation skills.
- Possession of valid driver’s license with access to a reliable insured automobile
Required Licensure/Certification/Education:
- Licensed LSW, LCSW, LMHC, LMFT in the State of Hawaii
- TB Clearance
- First Aid and CPR Certification
Preferred Qualifications:
- Bi-lingual in any of the following languages preferred: Ilocano, Tagalog, Mandarin Chinese, Japanese or Korean
- Ability to communicate using American Sign Language
Physical Demands/Work Environment:
- Possession of a valid driver’s license and auto insurance with access to a reliable, 4-wheel, safety- inspected vehicle.
- Medium work: Walking, standing, and exerting up to 40 pounds of force occasionally, or up to 25 pounds of force frequently, or greater than negligible up to 10 pounds of force constantly to move objects.
- May require prolonged sitting up to 4 hours.
- Requires operation of a computer workstation, including keyboard and video display terminal.
Salary Range: $78,000 - $83,000 annually
AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with
sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record), disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans’ status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.
